The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at other clients. What is the priority action of the nurse?
Attempt to deescalate the client.
Continue to observe the client for increased agitation.
Offer medications to help the client control behavior.
Ensure safety in the environment for the client and others.
The Correct Answer is D
A. Attempting to deescalate the client is important, but ensuring immediate safety is the top priority.
B. Continuing to observe the client may lead to a further escalation of the situation. Safety measures should be taken first.
C. While offering medications may be necessary, ensuring safety is the immediate priority before any interventions are implemented.
D. Ensuring the safety of the client and others is the priority in situations of escalating agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect. While maintaining proper nutrition is important, this statement is not directly related to the use of risperidone.
B) Correct. Risperidone, an atypical antipsychotic, can be associated with metabolic side effects, including hypertension. Therefore, monitoring blood pressure is important.
C) Incorrect. While regular monitoring of blood parameters may be necessary for some medications, it is not a specific requirement for risperidone.
D) Incorrect. While weight changes can occur with risperidone, there is no specific indication to increase caloric intake in this context.
Correct Answer is A
Explanation
A. Labeling the bathroom door can provide a visual cue to help the older adult locate the bathroom, which may reduce episodes of incontinence.
B. Taking the older adult to the bathroom hourly is a good strategy, but it may not always be feasible or effective in preventing accidents.
C. Using disposable adult briefs may be necessary at times, but it should not be the first line intervention.
D. Limiting oral fluids to 1000 mL/day may lead to dehydration and is not an appropriate intervention for addressing incontinence.
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